Allergy & Asthma Specialists Of Kansas City

Receipt Of Notice Of Privacy Practices Written Acknowledgement Form

I, _________________________, have had the opporlunity to read the Privacy Practices of Allergy & Asthma Specialists of Kansas City on their website. I am also aware that I can ask for and will be provided a copy of the Privacy Practices at the time of my appointment.

Patient Name

Patient or Legal Guardian Signalure Date

Allergy & Asthma Specialists of Kansas City

Patient Consent to Leave Detailed Message/Information

Allergy & Asthma Specialists of Kansas City has adopted a policy that requires our staff to obtain authorization from the patient to leave detailed messages for the

patient. This policy is to protect the patient and also to protect our staff from violating the patient’s confidentiality. If we do not have a signed consent on file, the staff may only leave their name and a phone number on an answering machine asking you to

call them back.

By completing the consent form below, the staff may call and leave their name, doctor’s name and additional information on an answering machine or with a specific

individual.

I give consent to my doctor and/or staff of AASKC to leave a message regarding treatment, lab results, or other information as necessary.

1. _____On voicemail. Phone #__________________________2. _____ With_________________Relationship & Phone #___________________3. _____I do NOT consent to messages being left. Please contact me directly.

__________________________________ Patient or Legal Guardian Signature

______________________________ Patient Name (Printed)

_________ Date

***Consent will be valid as long as patient is an active patient unless otherwise instructed .

Allergy & Asthma Specialists of Kansas City 6000 North Oak Trafficway Suite 102

Gladstone Missouri 64118 816-453-7771

NOTICE TO ALL PATIENTS

As of this date, Allergy and Asthma Specialists of Kansas City does not contract with any Medicaid plans with the exception of Missouri HealthNet. If you are insured by Missouri HealthNet, we will file your claims for you. Since we do not participate with any other Medicaid plans, you will be responsible for any charges incurred from your appointment(s) in this office. To prevent any billing issues, please inform the front desk of any insurance plan(s) you have.

I have been informed that AASKC does NOT take all Medicaid products. I am aware that if I participate with a Medicaid product that AASKC does not participate with, I will be fully responsible for any charges incurred.

Patient Name_____________________________ Date____________

Patient or Guardian Signature__________________________________

Allergy & Asthma Specialists of Kansas City

24 Hour Cancellation & “No Show” Fee Policy

Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. Therefore, AASKC reserves the right to charge a fee of $88 for new patients and $45 for established patients, for all missed appointments (“no shows”) and appointments which are not cancelled with a 24-hour advance notice.

“No Show” fees will be charged to the patient. This fee is not covered by insurance, and must be paid prior to your next appointment. Multiple “no shows” may result in termination from our practice.

Thank you for your understanding and cooperation as we strive to best serve the needs of all of our patients.

By signing below, you acknowledge that you have received this notice and understand this policy.

_______________________________________________ Patient Name (Printed)

______________________________________________Patient or Legal Guardian Signature

__________________ Date

__________________ Date

Online Access of Medical Records

Your medical records can be accessed online at www.IQHealth.com

IQ Health is a secure website provided by Cerner, our electronic

medical record host. We will need your e-mail address and a personal

security question to invite you to join the website. On the website,

you will be asked to provide login information and a personal security

question answer.

******Please print legibly. If we cannot read your e-mail address, we

will not be able to send you an invite.

Patient Name: _________________________________________________

Date of Birth: _________________________________________________

E-Mail Address:_________________________________________________

Security Question: Last 4 digits of SS#_______________________________

For patient confidentially and security, this form will be shredded after

the IQ Health invite has been sent.

Allergy & Asthma Specialists of Kansas City

Billing Agreement

Patient Name:_________________________________ DOB:___________________________

Due to the recent increase in high deductible plans, it is now the policy of Allergy & Asthma Specialists of Kansas City to require either a credit/debit card or HSA/Flexible Spending Card to be kept on fill for ALL patients. All visits will first be charged to your designated insurance carrier for services rendered.

If your claim comes back with a patient responsibility balance such as co-pay’s, co-insurance, deductibles etcetera, you will receive a statement. You will have 30 days from the statement date to pay your balance in full. Any remaining balances will then be charged to the card kept on file. All cards will be stored electronically in Payment Card Industry Compliant & Cyber Security Insured system which sets rules to minimize risks of data breaches on all accounts, truncating credit card information and keeping consumer’s date safe and private when payments are taken and stored. The card on file information visible to Allergy & Asthma Specialists of Kansas City is limited to the last 4 digits of your card number and expiration date. Your card on file can only be used to pay account balances incurred at our office, through our secured payment terminal powered by US Pay. If you pay your bills by the due date, your card will never be charged. If you would like to use the card on file to pay your bill, do nothing and the card will be charged on the date posted on your statement.

It is YOUR responsibility to notify us of any change to your insurance so that we can submit the charges to your carrier in a timely manner. It is also your responsibility to notify us if there is any change to your card on file so that the information can be updated. If you remove your card on file, we reserve the right to refuse further medical treatment as it is a violation of our billing agreement.

You, the Patient/Parent/Guardian/Co-Signer, by signing this agreement, agree to allow Allergy & Asthma Specialists of Kansas City to utilize your Credit/Debit Card or HSA/Flexible Spending Card to pay all fees and costs due to Allergy & Asthma Specialists of Kansas City at any time if money is owed after your primary insurance carrier has been billed or from amounts excluded from your insurance (i.e. Cancellation/No Show fees).

All account numbers and charges made by Allergy & Asthma Specialists of Kansas City are generally confidential and are protected from disclosure excepted as provided by the law.

Refusal to provide your credit card information to be stored is in violation of our billing agreement and therefore we reserve the right to refuse service to you. Your signature indicates your understanding and compliance with this policy.

______________________________ ______________________________ Patient Name Patient Signature ______________________________ ______________________________ Parent/Guardian Name Parent/Guardian Signature

Name on Card:_____________________________ Billing Zip Code:_______________

Card #______________________________________________________ CVV ___________ Expiration_________